gindegi goron - inee

Gindegi GoronResults from IRC’s audio initiative to support nurturing care for early childhood development in Cox’s Bazar during the COVID-19 pandemic

Table of Contents

Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Introduction: Early childhood development (ECD) in humanitarian settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

WhyECDmattersandthevalueofearlyinterventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

ThelackofECDresourcesinhumanitariansettings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

COVID-19:FurtherdisruptingaccesstoECDservices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Designing a remote-based ECD intervention in Cox’s Bazar, Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

RohingyarefugeesinCox’sBazar,Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

IdentifyinganeedforECDprogramming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

COVID-19hitsCox’sBazar,demandinganadaptedintervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

SummaryofECDassessmentfindingsduringCOVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

User Profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PrototypinganddevelopingGindegi Goron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ServicedeliveryofGindegi Goron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Results from Gindegi Goron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

MonitoringandEvaluationResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

OtherResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Cost of the initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Lessons learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Policy and program recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Authors

ThisreportwasauthoredbyKatelinWilton,KatieMurphy,AhsanMahmud,SyfulAzam,RuhulAmin,EmmaKaneandUnderstoryConsulting .

Acknowledgements

TheresearchdescribedinthisreportwascommissionedbytheDepartmentofMaternal,Newborn,ChildandAdolescentsHealthandAgeing(MCA)oftheWorldHealthOrganization .TheauthorsacknowledgethecontributionsofWHOstaffmembersPuraSolon,NigelRollins,MansukDanielHanandBernadetteDaelmansintheconceptualizationoftheresearchandthereviewoffindings .ThankyoutotheLEGOFoundation,SesameWorkshopandBernardVanLeerFoundationwhofundedinterconnectedwork .

TheIRCteamwishestothankicddr,b,specificallyDr .JenaHamadani,ShamimaShiraj,SyedaMehrin,fortheircriticalroleontechnicalsupportandcontentdevelopment .ThankyoutoShazzadKhanforhisdesignsupport .

ForthecasestudieswewishtothankKatieBarnum,KhurasanAliShahandHeidiRosbe .

Gindegi GoronResults from IRC’s audio initiative to support nurturing care for early childhood development in Cox’s Bazar during the COVID-19 pandemic

COVER IMAGE SOURCE: J Wanless / International Rescue CommitteeInternational Rescue Committee Rescue.org 1

Decades of rigorous research underscore the criticalimportanceofearlychildhooddevelopment (ECD)startingfrom conception through the first years of life .1 It is awindow in human development when experiences shapebrain architecture, serving as a foundation for learning,behaviorandhealth .Exposuretoviolence,separationfromcaregiversandthestressofdisplacementthreatenhealthydevelopment .Assuch,childrenbornandraised inconflictandcrisissettingsareatsignificantriskofnotreachingtheirfulldevelopmentalpotential,withconsequencesthatcanbehighlydetrimentaltochildren,theirfamiliesandtheirbroadercommunities .

There are several ways ECD interventions canmitigate this risk . A comprehensive approach to nurturingcareshouldfostergoodhealth,adequatenutrition,securityand safety, responsive caregiving and early learning . Butvery fewhumanitarianresponsesprioritize theholisticandinterrelated needs of young children and their families,and the COVID-19 pandemic significantly altered andoftenhaltedthedeliveryofECDprogrammingincrisisandconflictsettings .Giventhecentral importanceofECD, theIRChasadapted its existingECD interventions for remotedeliveryamidst theCOVID-19pandemic .Partof thatworkinvolves piloting new approaches, aligned with the fiveinterrelated and indivisible components of the NurturingCare Framework: good health, adequate nutrition, safetyand security, responsive caregiving, and opportunities forlearning .2ThisreporthighlightsexamplesoftheIRC’sECDprogramming during the COVID-19 pandemic, includingbriefsummariesofprogramminginPakistan,theMiddleEastandEastAfrica .Thisreport’smainfocusisonBangladesh,where the IRC isworkingwith partners on the ground todeliverECDprogrammingtopregnantandlactatingwomenliving in the Cox’s Bazar refugee camps and surroundingcommunities .

ThroughaprogramknownasGindegi Goron,aRohing-yaphrasefordevelopingfuture,theIRCdeliveredbehavior-ally informed messages to promote healthy developmentforpregnantmothersandtheir infantsviaphonecallsandtext messages from September through December 2020 .Theprogramreachedover400households,andanalysisofpilotdata indicatessuccess inpromotingbehaviorchangeinareasthatarecriticaltochildsurvivalanddevelopment .

Feedbackfromcaregiversdemonstratestheinterven-tion'sability tobothcloseknowledgegapsrelatedtoearly

childhooddevelopmentandpromoteresponsivecaregivingbehaviors . After receiving the IRC's Interactive VoiceResponse(IVR)calls,caregiversreportedthattheyadjustedtheirinfants'diets,consultedwithdoctorsafterexperiencingpregnancy complications and engaged in play with theirchildren . While this study was not designed to generateresults that can be generalized to the broader populationand draws from programmonitoring and evaluation data,thebaselineandendline survey results from 118 randomlyselected participants, demonstrate behavior change inthe areas of caregiver-child play, growth monitoring andcounseling,andreadingtothechild .

TheresultsofGindegi Goronsuggesttheimportanceand feasibility of deploying ECD interventions during theCOVID-19 pandemic in themidst of a humanitarian crisis,and the impact it canhaveonmothersand their children .Theresultswillalsoinformthenextiterationofthisprojectthrough the LEGO Foundation's Play to Learn initiative inpartnership with Sesame Workshop and BRAC . Throughthe analysis of the pilot data, the IRC demonstrated thatresponsivecaregiving,earlylearningandhealthandnutritioncan be promoted through remote programming, and canserve as a model for future interventions where there isrestrictedphysicalaccesstohighlyvulnerablepopulations .

Thisanalysisshouldencouragerelevantstakeholderstoinvestinandintegrateevidence-basedinterventions(likeGindegi Goron)thatbuildresilienceandmitigatetheharmfuleffectsofemergenciesonchildcarepracticesandchildren'sexperiences .

Executive summary

Key findings include:• 25%increaseinmothersreportingthatthey

playwiththeirchild(from80%to99%,p-value< .05)

• 38%increaseingrowthmonitoringandcounseling(50%to67%,p-value< .05)

• 7.25Xincreaseinmothersreportingtheyreadtotheirchild(from4%to33%,p-value< .05)

SOURCE: M Hasan / International Rescue Committee

International Rescue Committee Rescue.org 3Implementing Evidence-Based Nurturing Care in Cox’s Bazar During COVID-192

WhyECDmattersandthevalueofearlyinterventions

Adversity inearlychildhood*canhavesevereconse-quences on brain development, with reverberatingnegativeimpactsthatmaylasttherestofachild’slife .Globally,over250millionchildrenhavebeenidentifiedasatriskforfailingtoreachtheirdevelopmentalpoten-tialduetopoverty,lackofearlylearningopportunitiesandother factors that hamper responsive caregiving .Nearly1 in4children in theworld live inaconflictordisasterzone3andfacecompoundedrisksfromexpo-suretoviolence,familyseparationandloss,andweaksupportservices fromgovernmenthealthandeduca-tionsystems .

Childhood development experts agree that achild’s early life experiences shape long-term health,behavior and learning outcomes . The period of timebetweenthestartofpregnancythroughthefirstyearsofachild’s life ismarkedbytremendousvulnerability,particularly for women and children living in crisisand conflict settings . It is also a time when positiveexperiences and interventions hold the powerfulpotentialtotransformthetrajectoryofchildren’slives .

ECD interventions work to build physical andemotional resilience in children and their caregivers .Theseinterventionsemphasizeresponsivecareonthepart of parents and caregivers, as well as engaging,playful,earlylearningopportunitiesforyoungchildrensuch as singing songs, looking at and talking aboutpicture books and using household objects for play .Such interventions protect children from the adverseexperiencesofcrisisandconflict,andbolsterchildhooddevelopmentandsurvival .

ThelackofECDresourcesinhumanitariansetting

Compared to themagnitudeofneeds facingchildrenand families living in crisis and conflict, there is asignificantgap in thedeliveryof quality interventionsthatsupportECDinaholisticmanner .

In low- andmiddle-income countries that oftenserveashostcommunities for refugeeanddisplacedpopulations,nurturingcareinitiativesareoftenunder-fundedandstymiedbya lackofcoordinationamongthevarioussectorsnecessaryforimplementationand

delivery .AndevenwhenfinancingforECD-specificin-terventionsisprioritizedandcoordinated,servicesmaynotreachcrisispopulationsbecauseofalackofded-icated infrastructure .As a result, there is typically aninadequate in-countryprovisionof services that sup-portECDinaholisticmannerforrefugeeanddisplacedpopulations, further cementing development barriers,particularlyforeducationandresponsivecaregiving .

National financing gaps are mirrored in globaland national humanitarian response plans andaccompanying funding . An April 2018 review of 26activeRefugeeHumanitarianResponsePlans (HRPs)foundthatonly58%mentionednutritioninterventions,fewerthan25%mentionedsafetyandsecurityorhealthinterventions, 10%of them recommended responsivecareinterventionsandonly9%ofthemrecommendedearlylearninginterventions .EvenwhenECDgoalswerepart of anHRP, theprogramswereoften inadequatein scope compared to the populations in need .4 Forexample,theHRPforSyrianrefugeechildrencalledforearly education and responsive caregiving programstoreachjust150,000ofthe2 .5millionSyrianrefugeechildrencoveredbytheplan .

Asfordonors,ofthe$25 .2billioninhumanitarianaidreportedin2018,lessthan2%(US$463million)wasearmarked to support early childhood needs; of the$192billion total internationalassistance in2017,only3 .3%(US$6 .3billion)wenttoECDinemergencies .5

Researchshowsthat it ispossible for innovativelow-costprogramstodemonstrablyimprovearangeofoutcomesrelatedtoECDandparentingbehaviors .6Yet,research and implementation funding is also scarce,resultinginincompleteevidenceofwhatinterventionsmosteffectivelyimprovedevelopmentoutcomes .Asaresult, practitioners, policymakers and donors do nothaveconcreteinformationabouthowbesttoprioritizethelimitedresourcesthatareavailable .

This dearth of programming, readily availableevidence and financing is why the IRC invests innurturing care interventions in humanitarian settings,currently operating these interventions in more than17 country programs . The IRC bases itswork on thebest available evidence and an understanding of thespecific needs, contextual factors and constraints ofhumanitariansettings .Using thisknowledge, the IRCoffersarangeofECDprogrammingforbothchildrenand their caregivers, including: providing technicalassistancetoexistingprograms;pilotingnewprogramsand studying their impact; and advocating policymakerstoadoptthemosteffectiveinterventions .

COVID-19: Further disrupting access to ECDservices

COVID-19hasfurtherdisruptedaccesstoECDservices,as governments’ virus-mitigation efforts have leftfamiliescutoff fromessentialservices likehealthcare

andeducation .Withnoorlowaccesstotechnologyinrefugeecamps,therearefewwaysforserviceproviderstoadapttheirECDprogrammingtoremotedelivery .

Whileinnovativemodelsexist,increasedresourcesand political will are required to implement thesesolutionsatscale .TheGlobalHumanitarianResponsePlan forCOVID-19calls for$10 .3billion inworldwiderelief,butlittleofthisisdirectedatECD(withlessthan4%oftheplan’stotalaskforeducationasawhole) .7

GiventhecentralimportanceofECDinterventions,andtheuniquechallengesofdeliveringthemamidsttheCOVID-19pandemic, the IRC is focusedon adaptingits existing ECD programming to remote modes ofcommunication .PartofthatworkinvolvespilotingnewapproachestoECDinitiatives,includinginBangladesh,wheretheIRCisworkingwithpartnersonthegroundtotelephonicallydeliverECDprogrammingtopregnantand lactating women and their families living in theCox’sBazarcampsandsurroundinghostcommunities .

This report details the IRC’s pilot project inBangladesh, includingwhyitwasneeded,howitwasdesigned and implemented, and the initial outcomesforpregnantand lactatingwomenand their children .The early success, according to positive feedbackfrom caregivers, underscores the importance of ECDinterventions, the feasibility of delivering effectiveinterventions duringCOVID-19, and the value of fullyfunding ECD interventions in humanitarian settingsduringthepandemicandbeyond .

Introduction: Early childhood development (ECD) in humanitarian settings

* Typically defined by IRC and others as the period from birth to age 8.

CASE STUDIES OF OTHER IRC ECD RESPONSES IN COVID-19

ThisreportalsoshowcasesotherIRCECDresponsestotheCOVID-19pandemic .TheIRCadapteditsearlychildhoodprogrammingforchildrenandtheircaregiverstoreachmorefamiliesintheirhomesettingsthroughvariousdigital,radioandphone-basedinterventions .ThroughoutthisreportweshowcaseresponsesinPakistan,EastAfricaandtheSyria-responseregionoftheMiddleEast .Theearlyresultsarepromising .

SOURCE: Habiba Nowrose / International Rescue Committee

Implementing Evidence-Based Nurturing Care in Cox’s Bazar During COVID-19 International Rescue Committee Rescue.org4 5

RohingyarefugeesinCox’sBazar,Bangladesh

Since 2012, violence against the minority Muslimpopulation in Myanmar has forced hundreds ofthousandsofpeople fromtheirhomes;mostof thesepeople are from theRohingya ethnic group, now theworld’s largest stateless people . In 2017 alone, morethan 650,000 Rohingya fled to Bangladesh fromMyanmar .Morethan1millionRohingyarefugeesnowliveinBangladesh,intheworld’slargestrefugeecamp,locatedinCox’sBazar .8Thescaleofthedisplacementhascreateddangerouslyovercrowdedrefugeecamps,wherebasicservicesarestretchedbeyondtheirlimits .Many refugees have been living in the Cox’s Bazarcampsforat least threeyears,and it isunclearwhentheywillbeabletoreturntotheirhomecountry .

Ofparticularconcernarethedevelopmentalandeducational needs of the children living in the Cox’sBazar camps, who make up 52% of the population9andmorethan130,000ofwhomare4yearsofageoryounger .10

IdentifyinganeedforECDprogramming

Prior toCOVID-19, the IRC’seducation team inCox’sBazarconductedanassessmentoftheECDneedsofRohingyarefugeesandthoselivinginthesurroundinghostcommunitiesaspartofthePlay to Learninitiative,a collaboration generously funded by the LEGOFoundationandledbySesameWorkshopwiththeIRCand BRAC as implementing partners . Through focusgroupdiscussions(FGDs)withpregnantwomen,theirfamilies and communitymembers, the IRC identifiedgapsinECDknowledgerelatedtohealthypregnancy,breastfeeding, basic infant care, vaccination and thevalueofplay .

In the FGDs, families showed some awarenessofhealthynutritionpractices,butreportedlackingthemeanstofollowthroughonthem .Forexample,thoughmotherscitedmilkandeggsasnutritious,theywerenotalwaysabletoprocurethembecauseofcost .Ingeneral,mothers reported it was a challenge to identify, findand obtain foods thatwere nutritious and affordable .Pregnant women were aware of the importance ofadequate rest and avoiding heavy labor, but had no

sourceofsupportfromfamilymemberstoalleviatetheirextensivehouseholdworkload .TheIRCalsoheardthatfullchildhoodvaccinationwasinconsistent .

In other cases, caregivers based their nutritionpractices on misinformation . For example, expectantmothers reported that they were undereating in anattempttomaketheirbabiessmalltoavoidacesareansection .

And even when caregivers had both accurateinformation and the means to provide certain kindsof care, engagement was still low . Play with youngchildrenwasnotedassociallyacceptable,butwithlowengagement .Thevalueofplayforparticipantswastokeepchildrencalmandquiet,withlittleunderstandingofplayasapartofearlylearning .

These gaps in knowledge about nurturing careand theopportunityandmeans tobeable toaccesssuchcarearenotuncommonamongparentsingeneral,and can be especially pronounced in humanitariansettings, where parents are navigating the impact oftrauma and violence, the disruption of displacementandalackofessentialresourcesandservices .

BasedontheFGDs,andadditionalconsultationswithgovernmentandhealthofficials,theIRCdeterminedtherewasaneedforECDinterventionsinCox’sBazar .AstheIRCbeganplanningaserviceoffering,theirworkwasdisruptedbytheonsetoftheCOVID-19pandemic .

COVID-19hitsCox’sBazar,demandinganadaptedintervention

After theWorldHealthOrganization (WHO)declaredCOVID-19apandemic,governmentsacrosstheworldimposedvariousrestrictions,includinglockdowns,theshutdown of non-essential businesses and servicesand bans on social and recreational activities . InBangladesh, the government imposed a specializedlockdownontheCox’sBazarcamps,whichrestrictedexitandentrytotheareawithexceptionsforemergencyfoodandmedicalsupplies .

In May 2020, the first COVID-19 case wasconfirmedintheCox’sBazarcamps,andpublichealthexperts warned about the likelihood of rapid spread,giventhedifficultyofsocialdistancingandquarantining

amidst the camps’ high population density, and theshared use of latrines and handwashing facilitiesby multiple households . As of January 17, 2020, atleast 5,720 residents of Cox’s Bazar camps and hostcommunitieshavetestedpositiveforthedisease,with83deathsreported .

Thecampsremainunequippedtoadequatelydealwith the pandemic . With only seven testing facilitiesserving all of the Cox’s Bazar camps, the testingcapacityisinsufficientforthepopulationsize .Further,residentscontinuetocongregateinlargegroups,oftenwithoutmasks,asmisinformationaboutCOVID-19runsrampantinthecamps .Movementwithinthecampsbyhumanitarian relief workers remains restricted, withmostrelyingontrainedvolunteerresidentstoeducatethepublicaboutpreventingCOVID-19 .TheGovernmentof Bangladesh frequently bans internet use withinthe camps, lifting the ban at unexplained times . Thisintermittentaccesshasmade itespeciallydifficult forpublichealthworkerstoencouragepreventionefforts(mask wearing, hand washing) and to combat falserumorsaboutCOVID-19 .

Whilesomeofthecamps’ lockdownshavebeenlifted, most non-life saving and life-sustaining in-personservices remain shutdown .Forexample,priorto COVID-19, households in the Cox’s Bazar campswere visited regularly by community health workers;those visits are now suspended . Education serviceswere also suspended, with educators deployed toassist inCOVID-19awarenessandpreventionefforts .Withintermittentaccesstotheinternet,therearefewopportunities for Rohingya refugees to make use ofremote services . Operating within these limitations,theIRC—withtheassistanceofaBangladeshihuman-centereddesigner—identifiedapromisingmodalityofsupporting caregivers remotely without internet: thedeliveryofECDresourcesthroughtelephonecalls,textmessagesandaudiosupportmessages .

Summary of ECD assessment findings duringCOVID-19

To inform the design of remote ECD programmingduring COVID-19 in Cox’s Bazar, the IRC conducteda survey of pregnant and lactatingwomen and theirfamilies living in thecampsandthesurroundinghostcommunities .Thepurposeof thisassessmentwas tobetterunderstandtheimpactofCOVID-19onaccesstoECDservices,andtosolicitfeedbackontheproposedinterventiondesign,includingthepreferredmodeandfrequency of communication . The assessment wouldalsoserveasabaselineinordertocomparewithendline

results andassesshow the IRC’s interventionaffectskey outcomes related to health, nutrition, responsivecaregiving,earlylearning,andsafetyandprotection .

The IRC developed a questionnaire andidentifiedpotentialparticipantsthroughoutreachto14community-basedhealthandnutritionclinicsinCox’sBazar,bothinthecampsandinthesurroundinghostcommunities . A total of 434 women (289 lactatingand 145 pregnant) were surveyed . The surveys wereconductedoverthephonebyateamofsixenumeratorsusing TAB-based apps (CommCare) and closelysupervised and supported by IRC staff, with eachsurveylastinglessthan30minuteonaverage .

ThelevelofinterestinreceivingECDinformationandservices fromthe IRCwasoverwhelming:Nearly100%ofwomensurveyedexpressedinterestintalkingtotheIRC,andreportedthatnearly90%oftheirhusbandsand70%oftheirmothers-in-lawwerealsointerestedintalkingtotheIRC .Thesurveyidentifiedmorningasthebesttimetoreachpregnantandlactatingwomen(nearly75%preferringthistime) .Intermsofthepreferredmodeof communication, there was a divergence betweenrespondentslivinginthecampsandthoselivinginhostcommunities:>80%ofthoselivingincampspreferredaprerecordedvoicecall,while>50%ofthoselivingin

Designing a remote-based ECD intervention in Cox’s Bazar, Bangladesh

SOURCE: Tim Nesmith / International Rescue Committee


host communities preferred SMS texts . None of theRohingyaparticipantspreferredSMStext .Accordingtothewomensurveyed,forphone-basedcommunication,mothers and mothers-in-law would overwhelminglyprefer female callers, while husbands would slightlyprefermalecallers .

Inadditiontoinformingthemodeandfrequencyof contentdelivery, the surveyalsoaffirmedkeygapsinECDknowledge (summarized in the tableonpage8)thattheproposedinterventionwouldaimtofill .Themainthemesidentifiedweresafebirthplanning(>70%ofpregnantwomeninthecampdidnothaveadeliveryplaninplace),breastfeeding(>80%ofpregnantwomendid not have a clear understanding ofwhat exclusivebreastfeeding entails), vaccination (>35% of lactatingwomen reported that their mothers-in-law did not

encourage child vaccination), and the importance ofplayinchilddevelopment .

Finally, the survey measured the impact ofCOVID-19 on overall perceptions of health and well-being . Almost half of respondents noted negativechanges in their health level, and ~20% notedincreased levelsofstress .Nearly60%ofrespondentssaidtheirday-to-dayroutineshadchangedbecauseofCOVID-19,and40%ofthosenotedhavinglessaccesstohealthservicesasonekeychange .

Given the results of the assessment, the IRCdeveloped an intervention to fill key knowledgegaps, delivering behaviorally informed nurturing caremessagesviaprerecordedcalls,livecallsandSMStextmessages . This intervention is referred to asGindegi Goron .

Key results of the baseline assessmentPregnant women:

RESPONDENTS IN CAMPS RESPONDENTS IN HOST COMMUNITY

# of pregnant women 31 113

% of pregnant women with no delivery plan in place 71% 24%

% of pregnant women who did not understand exclusive breastfeeding

81% 83%

Lactating women:

RESPONDENTS IN CAMPS RESPONDENTS IN HOST COMMUNITY

# of lactating women 43 246

% of lactating women who did not practice exclusive breastfeeding

38% 29%

% of lactating women who cited “child’s development” as a reason for playing with child

6% 29%

CASE STUDY

Pakistan Reading ProjectThe Pakistan Reading Project (PRP) is a USAID-fundedinitiative supporting regional and provincial educationdepartmentstoimproveliteracyandreadingskillsofpublicschoolchildreningradesoneandtwo .Theproject,whichbeganin2013,hasreachedmorethan1 .7millionPakistanichildrenandtrainedmorethan27,000Pakistaniteachersinreadinginstruction(asofDecember2019) .

WiththesupportofthegovernmentofPakistan,PRPleveraged its large network of teachers and families todeliver COVID-19 preventionmessaging through variouscontent delivery channels, including PRP’s website,WhatsApp channel and weekly newsletters . Thosemessagesreached47,000teachers,educationofficialsandcommunitymemberseachweek .

PRP signed on with mobile service providers toreachanother5 .9millionmobilephone subscriberswithitsCOVID-19messagingandwithinformationonreadingresources for young children . This support includedsendingoutdecodablestoriestomobilephonesubscribersonaweeklybasis .A totalof 76stories in five languageshavebeensentviaSMS--eachwithaweblinktodownloadthepictorialversionofthebook .

For the 47,000 mobile phone subscribers, PRPpilotedInteractiveVoiceResponse(IVR)asanautomatedstorytellingsystem(featuring88storiesinfivelanguages) .With IVR, people with simple mobile devices andlandlinescouldcall inand listen to thestories .Forusersof smartphones, multimedia content was shared on aWhatsAppchannel . Intotal,PRP’s IVRnumberhasbeenaccessedmorethan70,000times .

Forradiolisten-ers, PRP broadcast-ed 103 prerecordedradio stories in fivePakistani languages .These stories wereproducedtoentertainaswellaseducate,in-corporating differentcharactervoices,mu-sicandsoundeffects .StoriesPRPrecordedwerealsopostedon thegovernment’seducationand lit-eracydepartment’sofficialwebsitesandFacebookpages .Thisnotonlyhelpedbroadenpublicaccesstothestoriesbutalsoservedtodeveloplocalownershipofthematerialsandteachingmethodologies .

To make the stories more interactive and involvefamilies of the students, PRP piloted live storytellingsessionstitled“DigitalDadiAmaa"(DigitalGrandmother)through an audio conferencing system . In all, 13 suchsessions were conducted with around 104 children . Attheendof eachsession, aquestionandanswer sessionwas held by the storyteller, where the children wholistened to the story with their parents on the phoneanswered comprehension questions related to the story .PRP, including itsCOVID-19response, receivedthe2020LiteracyAwardfromtheUSLibraryofCongressinhonorofitsexemplary,innovativeandreplicableworkonECDinhumanitariansettings .

SOURCE: M Hasan / International Rescue Committee


Tohelpfosteranunderstandingofthetypicalcircumstancesandexperiencesoftheirusers,theteamcreated“userprofiles”formothers,fathersandmothers-in-lawinboththecampsandthehostcommunity .Theprofilesarecomposites,andwerebasedoncommoncharacteristicsofthosewhoparticipatedinthebaselineassessment .Theuserprofilesfeaturedinformationontheusers’languagecapabilities,theiraccesstovarioustechnologiesandpotentialbarrierstoservicedelivery .Someexamplesofuserprofilesareincludedbelow:

User Profiles

Barriers to overcome

Barriers to overcome Barriers to overcome

Barriers to overcome

Infrastructure

Infrastructure Infrastructure

Infrastructure

Service Delivery Options

Service Delivery Options Service Delivery Options

Service Delivery Options

Featurephonesharedwithhusband

Featurephonesharedwithhusband

Usingson’sfeaturephone

Ownsfeaturephone

Sharedfeaturephone

Sharedfeaturephone

Sharedfeaturephone

Featurephone

Moderateelectricity

Solarenergy

Solarenergy

Solarenergy

Moderatenetwork

Moderatenetwork

Poornetwork

Poornetwork

Rohingyalanguage

Rohingyalanguage

Rohingyalanguage

Seldomplayswithkids

Moderatehouseholdsupport

TV

NoTV NoTV

NoTV

Healthclinicwithinwalkingdistance

Noaccesstohealthclinic



LivesinTeknaf .Hostcommunity

LivesinUkhiyacamp LivesinKutupalongcamp

LivesinUkhiyacamp

About

About About

About

SpeaksChittagonian

SpeaksRohingya

SpeaksRohingya

Lowdigitalliteracy

Nodigitalliteracy

Nodigitalliteracy

Nodigitalliteracy

Liveswithhusband,notin-laws

Liveswithin-laws

Liveswithson

Nodisability

Nodisability

Nodisability

Nodisability

Morethanonce

Morethanonce

Dailylabor

Notbreastfeeding

Breastfeeding

Breastfeeding

Lownutritionknowledge

Nonutritionknowledge



Mother

Mother Mother-in-law

Father

AnowaraPregnant mother with multiple children, living in host community

AnowaralivesinTeknaf,ahostcommunity .Sheisapregnant27-year-oldmotherwiththreechildren(ages3to11yearsold)andherhusband,whoisadaylaborer .SheisabletoreadBanglaandhassomebasicknowledgeofnutrition .ThereareseveralhealthclinicsinherareaandshewascomfortableseekingservicestherebeforeCOVID-19 .Sincethepandemic,Anowaradoesn’tgooutsidemuchsoastopreventriskofinfection,whichworriesheragreatdeal .Hertimeismostlyoccupiedbyhouseholdchores .Herchildrenmostlyplaywithoneanother,andshedoesnotfeelthattheyneedmuchtimefromher .Theexceptionishereldestdaughter,whosesafetysheworriesaboutandwhosheconstantlyprovideswithmoralandsocialeducation .

RumaLactating mother with multiple children, living in Shamlapur Camp

Rumaliveswithherhusband,twochildren(ages2yearsand6months)andherparents-in-lawinShamlapurCamp .Shedeliveredherbabyathomewithouttheaidofamidwifeorsomeonetrainedinsafedelivery .Instead,Ruma’smother-in-lawassistedinthebirth .Rumabreastfeedsheryoungestandgivesbothherchildrenhoney,milkandothersnacks .Rumahasnotvisitedthehealthpostsincethebeginningofthepandemic,asshefearscontractingCOVID-19 .Rumaenjoyssmilingatandtalkingtoherbaby,butrarelysingsorreadstoher .

KhadijaMother-in-law of a lactating woman, living in Jamtoli camp

Forthepasttwoyears,KhadijahaslivedwithhersonandhisfamilyinJamtolicamp .Sheis57yearsoldandspendsmostofhertimesupportingherdaughter-in-lawintakingcareofherfourgrandchildren,oneofwhomisanewborn .Shefeelssheshouldmakethekeydecisionsregardingtheircare,givenherageandexperience .Thoughthehorrorsofthepastarestillchasingher,shefeelssecurelivingwithherfamily .SheonlyspeakstheRohingyalanguage,anddoesnotknowhowtoread .Whenitcomestofamilymeals,Khadijaisfocusedoncaloricsustenanceratherthanbalancednutrition .ShelovestoreciteversesfromtheQuranandplaywithhergrandkids .

SalamatullahHusband of a lactating mother with multiple children, living in Ukhiya Camp

Salamatullah,a28-year-oldman,liveswithhischildren(twodaughtersanda7-month-oldson),hiswife,andhismotherinUkhiyacamp .Hedidn’tgotoschoolandnevervisitedanyhealthclinicswhenhelivedinMyanmar .Hehasadaylabourjobinthecampandhasreceivedsomebasicmedicinesfromthecampclinic .Heisprettysatisfiedwithlifehere,butisstillworriedaboutthefuture .Hetriestohelphiswifebybringingwaterandprocuringwoodforcooking,butthemajorityofhistimeisspentsearchingforlivelihoodopportunities .Whenhehappenstobehomeandhis7-month-oldsoncries,heholdshimandwalksaroundthehouse .


13

PrototypinganddevelopingGindegi Goron

The IRCpartneredwith the icddr,bMaternalandChildHealthDivisiontoprioritize,plananddraftthecontentfortheaudioscriptsandSMSandremotecapacitystrength-eningofthefacilitationteamtogetherwiththeIRCBan-gladesheducationteam .Thereweretwoprimary,in-per-sontestingsites,oneintheCox’sBazarcampsandoneinthehostcommunity .PrototypingwasconductedbyIRCstaffinAugustwitheightmothers,supportedremotelybyahumancentereddesigner .

BeforedevelopingthefullsetofscriptsthatwouldformthesubstanceofGindegi Goron,theIRCappliedaniterativeapproach,wherevariousprototypesweretestedwithsmallgroupsoflocalpregnantandlactatingwomenandthenrefinedbasedonthisfeedback .Basedontheresults of the assessment, the prototypes for the hostcommunityincludedcallscripts(inthelocalChittagoniandialect)andSMStextmessages(inBanglafonts),whiletheprototypesfortherefugeecommunityincludedonlycall scripts (in the Rohingya language) due to literacybarriersnotedintheassessment .

Based on the initial assessment and feedbackfrom prototype testing, icddr,b led in adapting theirevidence-based home visiting curriculum11 to developcall scripts and SMS messages focused on two keygroups:forlactatingwomen,therewouldbeafocusontheimportanceofplay,earlylearninganddevelopment,

combinedwithkeyhealthandnutritionmessagingandhow to adapt key caregiving responsibilities during apandemic;forpregnantwomen,therewouldbeafocusontheimportanceofnutritionandrestduringpregnancy .Religious referenceswould bewoven into the content,afteranemphasisfromtestsubjectsontheimportanceofprayerandreligioninstressreduction .

For both host and camp communities,messageswouldbesenttothepregnantandlactatingwomenaswellastotheirhusbandsandmothers-in-law .After lis-tening to the audio message prototypes, participantsrecommended thatmessaging should also target theirhusbandsandmothers-in-lawwhooftenmakedecisionsrelated to thehousehold, including familynutritionandhealth .Thisinsightintofamilydecision-makingbecameakeyelementofthedesignandapproachtopromotingbehaviorchangeinthehousehold .

ServicedeliveryofGindegi Goron

TheIRCdeliveredGindegi Gorontothesamepopulationof households that were part of the initial assessment(434pregnantandlactatingwomen,andtheirhusbandsandmothers-in-law) .

In addition to these calls, participants in the hostcommunities also received SMS textmessages, whichserved as truncated reminders of the informationcontainedinthecalls .Theinitiativedividedparticipants

FEB

2020 2021

MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN

Community engagement, FGDs and outreach to health clinics

Prototyping planned but cancelled due to COVID-19 [lockdowns]

Rapid Education Needs Assessment, phone based

Planning and implementation of Baseline ECD Assessment of Pregnant and Lactating Mothers, phone based

Creation of prototype messages [limited access is allowed] prototyping conducted in person; establishment of partnership with icddr,b

Facilitators are trained and begin calls; IVR platform is designed

IVR Platform delivers calls, SMS and quizzes, refresher training session and Q&A with facilitators and icddr,b

Endline survey is conducted, report finalized

Project timeline

SOURCE: Habiba Nowrose / International Rescue Committee

International Rescue Committee Rescue.orgImplementing Evidence-Based Nurturing Care in Cox’s Bazar During COVID-1912

andtheirfamilymembersintothreemaingroups:pregnantwomen, lactating women with babies younger than 6months,and lactatingwomenwithbabies7monthsorolder .Eachofthesegroupsreceiveddifferentmessagesonce aweek on 12 different topics spanning: nutrition,breastfeeding, the importance of play, child safety andotherkeyECDelements .For topics involvingplaywithobjects(books,blocks,balls,etc .),theIRCprovidedaplaykitwhichincludedthesematerialsfortheparticipants .

Indeliveringmessagesonthesekeytopics,theIRCcreatedcall and text scripts thatwere simple and easyto understand, culturally appropriate and empathic .Forexample,thecallscriptoniodinethatwenttopregnantwomenreads:

Greetings from IRC. Iodine is a very important mineral for the developing fetus. To get an adequate amount of iodine, you should always use iodized salt. You can check if there’s iodine in the salt by mixing it with a few rice grains and a drop of lemon juice. If there is iodine in the salt, it will turn blue. Continue to consume this salt! Salt should be stored away from sunlight and heat and in a closed container, otherwise iodine will vaporize in the air. Iodine is also available in potatoes with the skin on, eggs, milk and seafood. Iodine is the essential nutrient for the healthy brain development of your fetus. Iodine deficiency during pregnancy leads to low IQ and behavior problems in your child. Thanks for listening!

One call script delivered to lactating women withbabiesbetween0-6monthscoveredinteractionswiththebabywhilebreastfeeding:

While breastfeeding your baby, the baby's head should be aligned with the baby's body; the ears, shoulders and lower back should form a straight line, facing your breast. You can interact with your baby during breast-feeding. You can look into the child’s eyes and sing some songs or recite religious songs for her/him. Call the baby by his/her name, if the baby has a name. Oth-erwise you can call him/her “baby” with a smiling and affectionate face. This will stimulate the baby and help him/her recognize his/her name. Talk and smile at the baby. Respond to all vocalizations. If s/he says “gogogo” you can say “gogogo” back to her/him. Stroke the ba-by’s head, forehead, hands and feet gently and talk to him/her. Thanks for listening!

Onecallscriptdeliveredtolactatingwomenwithba-biesbetween7-12monthscoveredreadingpicturebookswiththebaby:

Greetings from IRC. Today we will recommend reading picture books with your baby! Teach him/her to turn pages. S/he might turn several pages at a time, but it is ok and you should be patient. When showing the pictures, point to each picture and say the name of that picture, then show the real thing if possible e.g. show him/her the picture of the rickshaw and then

WEEKS PREGNANT WOMEN LACTATING WOMEN WITH BABY <6 MONTHS OLD

LACTATING WOMEN WITH BABY 7 MONTHS OR OLDER

Week 1 Importance of antenatal care (ANC) check-ups during pregnancy

Importance of immunizations, and adhering to the timeline The benefits of play and singing songs

Week 2 Nutrition: getting enough iodine Playing peek-a-boo Mental health and well-being

Week 3Nutrition: folic acid and iron Benefits of breastfeeding baby Making the home environment safe for

crawling and walking babies

Week 4 Nutrition: eating a balanced diet Benefits of play and singing songs Introducing complementary foods

Week 5Avoiding tobacco Positive interactions with baby during

breastfeeding Peek-a-book with a toy

Week 6 Avoiding un-prescribed medicine Playing with a soft ball Playing with blocks and container

Week 7 Mental health and well-being Mental health and well-being Healthy, balanced diet

Week 8 Preventing falls and avoiding lifting heavy objects

The benefits of expressing love to your baby Avoid physical maltreatment

Week 9 Growth and movement in the womb Methods of breastfeeding Play with a mirror and baby’s reflection

Week 10 Danger signs during pregnancy Introducing the baby to books Learning to turn pages of a picture book

Week 11 Gender equity: preparing for a girl child Breastfeeding challenges: sore nipples Learning the names of body parts

Week 12 Preparing for safe delivery Playing with blocks Making mealtimes fun

Participantsreceivedweekly,prerecordedcallsonkeyECDtopics

SOURCE: Iris Ebert / International Rescue Committee

International Rescue Committee Rescue.org 15Implementing Evidence-Based Nurturing Care in Cox’s Bazar During COVID-1914

slightlymodifiedtoaddressthespecificroleahusbandor mother-in-law should play in maternal and childwell-being .

In addition to the weekly prerecorded callsand text messages, participants received biweeklyquizzes to reinforce understanding of key elementsof ECD knowledge; and biweekly phone call check-ins from trained IRC facilitators,which served as anopportunityforparticipantstoaskquestionsandshareinsights,andfortheIRCtoofferencouragementandsupport .Participantscouldrequestacallbackfromafacilitator,sononeoftheirownmobilephoneairtimewasrequired .

The delivery of Gindegi Goron ran from September through December 2020.

show him/her a real rickshaw. Name each picture and then ask your baby to touch that picture. Help him/her by holding his/her hand if necessary. Make the sounds the vehicles make, for example: car sound peep peep; rickshaw sound tung tung; honda sound bhu bhu etc. Encourage your baby to imitate vehicle sounds and have fun. Praise the baby for looking at the book, pointing at pictures, vocalizing, saying words and/or turning the pages. S/he will learn to speak a lot faster when you talk with him/her about the pictures and will also learn the names of those pictures. Thanks for listening!

For each message delivered to a pregnant orlactatingwoman,therewasacorrespondingmessageon the same topicdelivered to thewoman’shusbandandmother-in-law .Insomecases,themessageswere

Throughout the implementation, the team remotelyprototypedahandbooktosupportfacilitatorsdeliveringthecalls .

In the initial design goals, the IRC identified theneedforfacilitatorstoreinforcetheautomatedmessageswith interactive, supportive communication . FacilitatorsareakeypartoftheIRC’snurturingcarework,andwereespeciallycentral to thisproject,as theywere theonlymajorpointofIRCcontactinthisremotedeliverymodel .The design of the IRC’s facilitator handbook becameespecially crucial . It served as a detailed roadmap todevelopfacilitatorknowledgeandcommunicationskillsand includedadditional spaces for takingnotes .Thesenotesectionsprovidedaplaceforfacilitatorstodocumentreal-time feedback from the users, as well as userquestionsaboutnutritionandnurturingcareinformationnotincludedintheguide .

Toensurethematerialwasaccessibletofacilitatorsandprovidedallrelevantinformation,theIRCiteratedtheguidethreedifferenttimes .Theiterationswereinformedbyinputfrom20facilitators .Duringtheiterations,theIRCheardfromfacilitatorsthattheinitiativeneededtobettertargetthemessagestospecificmilestonesofamother’sexperience in pregnancy, birth, and post-natal care . Inresponse,theIRCsplitthemessagesintothreedifferentsegments to fitwith thestagesofamother’spre-andpost-nataljourney .

Facilitator'sHandbook

SUNDAY IVR calls placed with messages for pregnant and lactating women in host community

MONDAY IVR calls placed with messages for pregnant and lactating women in Rohingya community

TUESDAY IVR calls placed with messages for husbands and mothers-in-law in both the host and Rohingya community

WEDNESDAY SMS texts sent to participants in the host community

THURSDAY IVR quiz (scheduled for every other week for pregnant and lactating women)

ExampleofweeklyinterventionscheduleExampleofweeklySMStext


Results from Gindegi Goron

n=434 women

Participants by community lived in

Pregnant women Lactating women

Camp Host

0

100

200

300

31

114

5

246

n=434 women

Participants by stage of pre- or post-natalcare upon enrollment

Pregnant women

Lactating women (baby 0-6 months)

Lactating women (baby >7 months)251 (57.8%)

145 (33.4%)

38 (8.8%)

n=7948 calls

Prerecorded call answer data

Call Answered

Call not picked up

Call not properly placed (technical issue)

3.9%

66%

30.1%

Engagement with prerecorded calls by monthn=3403 calls

October November December

Did not press any key Pressed a non-formated key

Requested repeat playRequested follow-up duscussion with facilitator

0%

25%

50%

75%

100%

Engagement with prerecorded callsn=3403 calls

Requested repeat play

Pressed a non-formated key

Did not press any key

Requested follow-up duscussion with facilitator

8.4%

15.8%

5.7%70.1%

TheGindegi GoronInitiativeenrolledatotalof434pregnantandlactatingwomen,theirhusbandsandmothers-in-law(iftheylivedinthesamehousehold) .

~80%ofparticipantswerefromhostcommunities,while~20%ofparticipantslivedincamps .

Theprerecordedcalldeliverymechanismwaseffectiveinreachingcaregivers .Ofthenearly8,000prerecordedcallsplacedoverthecourseoftheinitiative,66%wereansweredbyprogramparticipants,30%werenotpickedup,and4%werenotproperlyplacedduetotechnicaldifficulties .

However,datasuggeststhatengagementratesdeclinedslightlyoverthecourseoftheinitiative .Requestsforrepeatplayheldrelativelyconstantfrommonth-to-month,butrequestsforfollow-updiscussionwentfrom17-18%frequencyinOctober-Novemberdownto11%frequencyinDecember .

Call duration by monthn=5247 calls

October November December

Call duration below 40 seconds Call duration above 40 seconds

0%

25%

50%

75%

100%

However,thedatasuggeststhatfeweransweredcallswerelistenedtothroughcompletionastimewenton(~75%ofansweredcallswerelistenedthroughtocompletioninOctober,comparedto~60%inNovemberand~65%inDecember) .

Attheendofeachprerecordedcall,participantscouldrequest(viatheirphonekeypads)thattheprerecordedmessagebereplayedorthattheybeconnectedwithafacilitatorforafollow-updiscussion .Incaseswheretheentirecallwaslistenedtoandthiskeypadengagementstagewasreached,participantsrequestedafollow-updiscussionwithanIRCfacilitatorover500times(16%)andrequestedthatthemessagebeplayedbacknearly300times(8%) .

n=5247 calls

Prerecorded call duration

Call duration below 40 seconds

Call duration above 40 seconds

35.1%

64.9%

Intheinstanceswherethecallwasanswered,themajorityofthesecalls(65%)lastedformorethan40seconds,whichwasthestandardlengthofeachprerecordedmessage,andindicatesthatthecaregiverlistenedtothemessageinitsentirety .


% of mothers reporting they play with their child

% o

f wom

en

(p-value < .01

Baseline Endline0%

25%

50%

75%

100%

80%

100%

Satisfaction with quality of the initiative

Somewhat satis�ed

2.5%

Very satis�ed

97.5%

Do you think that the service you recieved from theIRC will improve your quality of life in the future?

Completely

Yes, very much

Somewhat

Not very much

Do you think that the service you recieved from theIRC will improve your child’s life in the future?

Completely

Yes, very much

Somewhat

Not very much

Monitoring and Evaluation Results ToestimatetheeffectsofGindegi Goron,apost-interventionendlineassessmentwasconductedandcomparedtothebaselineassessment .Theendlineassessmentincludedarandomsampleof118women(camp=24women,hostcommunity=94),asamplerepresenting27%ofthebaselinegroup(n=434) .Forthese118participants,endlineresponseswerematchedtobaselineresponsestomeasurechangesinparentingbehaviorsrelatedtokeyECDoutcomes .Datacleaning,mergingandanalysiswasconductedinRandRStudiostatisticalpackagesandincludedanalysesofbasicdescriptivestatistics,includingWilcoxonranksumtestswithcontinuitycorrection .Caregivingpracticesandparentingbehaviorsatbaselinewereonlycollectedfrommotherswithinfants(lactatingwomen,n=60),andnotpregnantwomen .Thus,pairedtestswereusedtoanalyzeindividuallevelchanges,usingtheresponsesfrommotherswithinfantsatbaselinepairedwiththeirresponsesatendline .Asthedatawerecollectedaspartofapilotstudyandnotdesignedtoproduceresultsthatcanbegeneralizedtoabroaderpopulation,akeylimitationisthesmallsamplesizes,whichlimitsthestatisticalpowerandourabilitytodetectdifferencesamongsub-groups .

Increaseinplayactivities

Whilethemajorityofcaregiverswithyoungchildrenreportedthattheyplaywiththeirchildrenatbaseline(80%,n=48),allofthesemothersreportedplayingwiththeirchildrenatendline(100%,n=60),anincreaseof25%,andastatisticallysignificantdifference(p-value< .01) .Whenaskedaboutthetypesofactivities,themostcommonactivitiesatbaselinementionedweretalking,smilingandgazingattheirchild .Atendline,inadditiontotalking,smilingandgazing,50%ofcaregiversalsomentionedplayingwithhouseholdobjects .Othersalsomentionedplayingwithblocksandsinging .

Increaseinheightandweighttracking

Motherswithinfantsatbaselinewereaskediftheymonitoredtheirchild'sheightandweightatbaselineandagainatendline .Thistypeofmonitoringisconductedathealthfacilitiesornutritioncenters,andisaccompaniedbycounselingtosupportnutritionandhealthygrowth .Atbaseline,50%ofmothers(n=30)reportedthattheytooktheirchildtohealthornutritionservicesforgrowthmonitoring .Whenthesamegroupofmotherswereaskedatendline,67%ofmothers(n=40)reportedthattheybroughttheirchildtoservicesforgrowthmonitoring,anincreaseof34%(p-value< .05) .

Increaseinmothersreadingtochildren

Inadditiontotheplayactivitiesmentionedabove,therewasastatisticallysignificantincreaseinmothersreportingthattheyreadtotheirchild .Atbaselineonly4%(n=2)ofthemotherswithinfantsreportedreadingtotheirchild .Therewasastatisticallysignificantdifferenceatendline(p-value< .01)with33%ofmothersreportingthattheyreadtotheirchild .

Increaseinhomebirths

Thoughthiswasnotanintendedoutcome,therewasanincreaseinthefrequencyofhomebirthsfrombaselinetoendline .Amonghomebirthsacrossbothbaselineandendline,traditionalbirthattendantsarethemostcommonsupportthatwomenreceive .Qualitativeresponsescollectedinthequestionnaireshedlightonapossiblecauseoftheincreasedratesofhomebirths,asparticipantscitedmovementrestrictionsandfearofinfectionthatcamewiththe

% of mothers reporting that they bring their child tohealth or nutrition services for growth monitoring

% o

f wom

en

Baseline Endline0%

25%

50%

75%

100%

50%

67%

(p-value < .05)

% of mothers reporting that they read to their child

% o

f wom

en

Baseline Endline0%

25%

50%

75%

100%

4%

33%

(p-value < .01)

COVID-19pandemicasreasonswhytheydidnotwanttovisittheclinic .

ImprovementsinnurturingcarebehaviorswerealsoreflectedinqualitativefeedbackfromparticipantsinGindegi Goron .Forexample,oneofthepregnantwomeninthehostcommunitydescribedhowtheprogram’scontentinfluencedherdecision-making:“AfewdaysagoIfacedacomplicationwithbleedingduringpregnancy .ButIreceivedanaudiocallmessageearlierthatmentionedwhatIshoulddointhissituation .That’swhyIvisitedaclinic,gotaconsultationfromadoctorandnowIfeelbetter .’’

Thisqualitativefeedbackwascollectedbytheprogramfacilitatorsinthecourseoftheirengagementwithprogramparticipants .

Other results Thebaseline-endlinesurveysalsosoughttomeasurecaregiverreportedtimelyvaccination,antenatalcarevisits,useofpositivecopingskills,specificearlylearningactivities,butnosignificantchangeswereseenintheseareas .TheIRCwillcontinuetoexamineitsinterventionmodeltodeterminehowbesttoadvancetheseimportantnurturingcaregoals .

Participantsatisfaction

Thosethatparticipatedintheendlinesurveywerealsoaskedabouttheirsatisfactionwiththeprogram .Caregiverssawthevalueandhadahighrateofsatisfactionwiththeprogramandcontent .97%reportedthattheywere“verysatisfied”withthequalityoftheprogram’scontent,andwiththefriendlinessandthetoneoftheprogram’sfacilitators .

92%ofprogramparticipantsindicatedthattheprogramwouldimprovetheirqualityoflife“completely”or“verymuch”inthefuture .

95%agreedthattheprogramwouldimprovethequalityoftheirchildren’slives“completely”or“verymuch”inthefuture .

“AfewdaysagoIfacedacomplicationwithbleedingduringpregnancy .ButIreceivedanaudiocallmessageearlierthatmentionedwhatIshoulddointhissituation .That’swhyIvisitedaclinic,gotaconsultationfromadoctorandnowIfeelbetter .’’


Theprogramactivitiescostanaverageof$285perhouseholdindirectcosts(or$341includingindirectcosts)forthefivemonthintervention .††Thisincludesboth direct and indirect costs, and also accountsfor significant one-time startup and initial designexpenses . It also includes messaging multiplemembers of thehousehold .After subtracting start-up costs, technical support and shared costs forofficesupport,therunningcostsformaintainingkeyprogramstaff, transportation, trainingandmaterialsis $165 per household or $33 per household permonth . As the program is scaled tomore programparticipants, costs per household would decreaseeven further . Costs of this pilot phase are brokendowninthegraphbelow .

Asistypicalofnurturingcareprograms,stafftimemakesup the largestprogramexpenditure .Nationalstaff, including facilitators and on-site researchers,represented 44% of costs; while international staff,including ECD program staff, represented another

17% .Anexternalpartnerwashiredtosupportcontentdevelopment, representing 19% of total costs . Theremaining costs were a combination of programmaterials (such as books, wooden blocks and softballs),travelexpensesandgeneraloverhead .Programmaterials were intended for distribution, which waslater canceled due to a second wave of COVID-19cases .We intend todistribute thesematerialswhenappropriate .

Deliveringan intervention remotelyoffers costadvantages compared to in-person delivery . (Perhousehold,IRC'sin-persongroupparentalcoachingprogramshavecostdoublewhattheremoteGindegi Goron Initiativedid .)Without a comparative impactevaluation, we cannot determine which mode ofdelivery (remote or in-person) is more effective .However,thisinterventiondemonstratesthepotentialof a remote modality for reaching a large numberof people in an acute emergency where access islimited,atarelativelylowcost .

Gindegi Goron - Cost Breakdown

Other

2.5%

Indirect cost recovery

5.3%

Materials

5.2%Travel

6.7%

Technical Unit staff

17.4%

Content development partner

19.0%

Bangladeshcountry

of�ce staff

43.8%

Cost of the initiative

CASE STUDY

PlayMatters in East AfricaIn 2019, the LEGO Foundation awarded a $100 milliongrant to increase learning through play opportunities for800,000 pre-primary and primary school aged refugeeand host community children in Ethiopia, Uganda andTanzania . This historic initiative is reimagining learningwithin the social ecosystems in which children live andlearn . Through bringing playful learning experiences intotheirhomes,schools,andcommunities,theprojectaimstobuild children’s social, emotional, cognitive, physical, andcreative skills to contribute to their long-termwell-being .The project, “PlayMatters: Sparking Lifelong LearningThroughPlay,”isledbyaconsortiumofhumanitarianrelieforganizations .†

PlayMatters’ interventions were in their nascentstagesofdevelopmentwhentheCOVID-19pandemicforcedschoolclosuresaroundtheworld,includinginEastAfrica .Whileministriesofeducationandother serviceprovidersfocused on delivering an at-home academic curriculum,PlayMatters prioritized addressing caregiver stress andmitigatinglearninglossthroughplay-basedmethodologiesthatengagethewhole family inreading,math,andsocialandemotionallearning(SEL)activities .AtthecenterofthePlayMattersCOVID-19responseinterventionisaseriesofpaper-basedhomelearningguides:PlayMattersatHome .The guides provide a recommended daily routine, tips

for well-being, suggestions for caregivers on storytellingpractices, and how to use every day interactions, suchas household chores or casual conversation, as learningopportunities .

The IRC has heard from caregiver participantsabout the impact the program is having on them andtheir children . Yein is a refugee and early childhoodteacher in the Gambella region of Ethiopia, who couldnolongerteachhisclassduetoCOVID-19 .Heobservedthenegativeimpactsofschoolclosureonthechildreninhis community—including his own three children .WhenhestartedusingthePlayMattersatHomematerialswithhis children, they startedpracticing the learninggames .“Myneighborsandotherpeople in the camparehappyand are continuously using the packets to support theirchildrenlearninaplayfulmanner,’’hesaid .Theteamalsodevelopedaguideforeducatorsonhowbest tousethePlayMatterslearningpacket,andhowtosupportpersonalandcommunitywell-being .

Finally, PlayMatters producedPlayMatters atHomeRadio Programs, which incorporated activities from thepackets and provided health and hygienemessages in aseries of broadcasts . Caregivers reported that the tonewas friendlyandeasy tounderstandand thesongswereespeciallyfunandengagingforchildren .

† Other consortium members include: Plan Børnefonden (Plan), Stichting War Child (WarChild), Innovations for Poverty Action (IPA), and the Behavioral Insights Team (BIT). †† Costing of the program was conducted using Dioptra, a new inter-agency program costing tool

developed by IRC’s Best Use of Resources team.

SOURCE: Mohamoud Farah / International Rescue Committee


Specific, audience-tailored messages were morechallengingtoimplementwithIVR

The IVRdesignwas complicateddue to themultipleunique groups of participants: mothers in differentstages of pregnancy or lactation, fathers/in-laws,and Rohingya/Chittagonian speakers . There was theadditional challenge of participantsmoving fromonegrouptoanother,forexample,whenapregnantwomangavebirth .Astheprogramgrowsandbeginsenrollingfamiliesonarollingbasis,thesystemwillhavetotrackthe diversity of participants on a weekly basis, anddeliverIVRmessagesaccordingly .

Exploreintegratedmessagingtechniquestoreducecost

Thispilotprojectofferedthreeseparatemessagingtractsfor three targeted groups: pregnant women, lactatingwomen with babies aged 0-6 months, and lactatingwomenwith babies aged 7months and older . It alsoaddressedprogrammingareaswhicharecriticaltobothhealth, nutrition and education sectors . It is critical toexplorewaysthathealthandeducationactorscanmeetthe overlapping needs ofmothers and childrenwhichleveragesbothsectorexpertisetobetterrespondtotheinterconnectedneedsofcaregiverparticipants .

AhlanSimsim, a partnership betweenSesameWorkshopandtheIRC, isthelargestECDinterventioninthehistoryof humanitarian response,with the aim of reaching 9 .4Mchildrenviaeducationalbroadcastsand1 .5Mchildrenviadirectserviceseveryyear .In2017,theIRCin partnership with Sesame Workshopwon the MacArthur Foundation’s first-ever $100million “100&Change'' awardto restore hope and possibility for ageneration of children in the Syrianresponse region (Iraq, Jordan, Lebanonand Syria) . In December 2018, theLEGO Foundation joined these efforts,awarding an additional $100 million toSesameWorkshop,BRACandtheIRCtobringthepoweroflearningthroughplaytochildrenaffectedbytheRohingyaandSyrianrefugeecrises .

When the COVID-19 pandemicwas declared, the IRC Ahlan Simsimteam rapidly adapted its programmingand developed new content to meetthe need for remote interventions forcaregiversandchildren includingamixof phone call- and digitally-deliveredprogramming . In April 2020, the IRCcreatedandmoderatedcaregivergroupsvia WhatsApp in Iraq, Syria, LebanonandJordan,throughwhichIRCdeliveredand facilitated conversation covering aseries of text, audio and visual content over a two-weekperiod . Content focused on a variety of topics including:COVID-19 prevention measures such as handwashingandsocialdistancing;ECDprogrammingemphasizingthe

importanceofplayandsampleactivitiesthatcanbedoneinthehomewhileschoolsareclosed;andstressmanagementtechniques for caregivers and children . Shared contentincludedvideoclipsandepisodes from theAhlan Simsim

TVshow .Building on feedback from the

WhatsApp caregiver group participants(through phone surveys of 1,000caregivers) the IRCAhlanSimsim teamimproved and scaled the next iterationof this digital messaging program forcaregivers . As of September 2020,the IRC has reached almost 19,000caregivers inLebanon, Jordan, IraqandSyria through its WhatsApp-deliveredprogramming .

Further, the IRC’s Ahlan Simsimteam adapted its Reach Up and Learnhome visiting program to be effectivelydeliveredoverthephonebycommunityhealth volunteers using scriptstargeted to specific age groups, withoverwhelming positive response fromthe caregivers . Lastly, a new phone-deliveredschoolreadinessprogramwasco-createdbytheIRCandtheMinistryofEducation in Jordan, preparing childrenfor successful entry into grade oneand helping their parents/caregivers tosupportthisgrowth .

ThroughtheworkoftheAhlanSimsimteam,theIRCwasoneofthefirstorganizationstoprovideearlylearninganddevelopmentservicesduringCOVID-19tochildrenandtheircaregiversintheMiddleEast .

CASE STUDY

Ahlan Simsim in the Middle East Region

The implementation and results of the pilot projectprovidedsomeimportantlessonslearnedfortheIRCas it works to scale the reach of itsGindegi GoronInitiative .

Outreachtocaregiversshouldextendbeyondhealthclinics

The IRC relied on health clinic rosters to identifypregnant and lactating women for enrollment inthis pilot program . While this led to the successfulenrollment of households in the pilot project andallowed the IRC touseexisting infrastructure tobuildits pilot project, the IRC recognizes that health clinicrosters,which representa fractionofcampresidents,arenotrepresentativeofthecamppopulationtotalasawhole .Inordertoreachallcaregiversinaparticulararea, the IRCwouldneed toexpand thecollaborativepartnerships .

Reaching caregivers in camps requiresmore stafftimeandoutreach

Duetotheday-to-daystressesoflifeinthecampsandtherelativelackofavailablecommunicationtechnology(internet,phone),itishardertoreachparticipantsinthecamps than inhostcommunities .Thiswasespeciallytrue during the pandemic, where in-person outreachwasseverelylimited .

Engagementratesindicatesomedrop-offmightbeexpected

Engagement rates of the pilot project participantsdeclined slightly each month . The IRC saw a similartrend in its Pakistan Reading Project’s COVID-19responseinterventionaswell,withlistenerengagementslightlydecliningoverthecourseoftheintervention .Inanattempttosolveforthis,theteamreviseditsprotocoltoallowuserstodial-inatatimeoftheirconveniencetohearstoriesandmessages theypreviouslymissed .(For more information on the project, see page 9 of

thisreport .)TheIRC’sendlinesurveydoesnotindicatewhyengagementlevelsdeclinedslightlyastheprojectprogressed,and the IRCwill continue toexamine thecauses of disengagement and strategies to maintainhighengagement .

Phone access and literacy limitations impactinterventionstrategies

Noteverycaregiverinthecampsandhostcommunitieshas their owndedicatedmobile phone,meaning thatsome households share a mobile phone . This factmade it difficult to ensure the appropriate caregiverreceived the messages tailored to them . In addition,poor telecommunication networks in the campsmadeitdifficult forRohingyacaregiverstoparticipateconsistently .

Phone-basedquizzeshadlowengagementrates,and caregivers often explained to facilitators that thequiz calls were unclear to them . This is another signthatphoneliteracyis limitedthat interventionsshouldbe designed with this in mind . Facilitators reportedthat phones were often switched off or unreachableduetonetwork issues,sorepeatedattemptstoreachparticipantshadtobemade .

Culturallyrelevanttoolsarenecessarytomaximizeresults

When interventions are grounded in cultural andcontextualrealities,theycanbehighlyvaluedbyfamiliesand communities experiencing crisis . For example,handmade dolls are often an important element ofthe IRC’sECD interventions,with variousdoll-relatedactivitiesbeingusedas tools for linguistic,socialandemotional development . However, dolls were lesssocially accepted among the programparticipants inthiscase .TheIRCcreatedplaykitsincluding13booksdevelopedbyicddr,b,woodenblocksandasoftball,butthesecouldnotbedistributedduetoasecondwaveofCOVIDinfectionswhichpreventedalldistribution .

Lessons learned


Policy and program recommendations Basedontheresultsofthepilotproject,lessonslearnedfromitsimplementation,andadditionalevidence-basedbestpracticesinthefieldofnurturingcareinterventionsinvulnerablepopulations,theIRCmakesthefollowingrecommendationstokeystakeholdersinprogramfundinganddelivery:

Increasedpoliticalwillandinvestmentinnurturingcareinitiatives• Nurturingcaremustbeembeddedinreproductive,maternalandchild

health,nutrition,education,andprotectionsectorpolicyandplansamongbothdevelopmentandhumanitarianauthorities .

• Investmentsshouldbeprioritizedtocatalyzeholisticoutcomesaswellasthemonitoring,evaluationandresearch .Foreignassistancecanbepairedwithdomesticfinancialcommitments,particularlygiventhelimitationsimposedbyCOVID-19 .

• Clarifyresponsibilityandaccountabilityforearlychildhooddevelopmentinhumanitariansettings,giventhatthesetypesofservicesarehistoricallyunderprioritizedandunderfunded .

Increasedintegrationofnurturingcareinitiativesacrosshealth,education,nutritionandprotectionsectors• Interventionsmustbeintegratedacrosshealth,nutrition,educationandpro-

tectionsectors .Thisincludesleveraginglocalexpertisetoidentifyinterven-tionsthatmeetthediverseandoverlappingneedsofparentsandchildren .

• Innovativedeliverymodalitieswhichfosternurturingcareshouldbescaledsothattheyareavailablefromtheveryfirstpointofcontactwithachildandcaregivertoensurenochildisleftbehind .

• Considerwhichoutreachchannelsprovidelow-costandlow-contactengagementopportunitieswithawidevarietyofcaregiversandactivatethemforwideruse .

• Morespecifically,integratingaphoneandIVR-basednurturingcareapproachtosupportpregnantandlactatingmotherscandelivertargetedengagementwithmothersandchildreneverywherewhichhasapplicationsforfamiliesonthemove .

Increasedmonitoringandrigorousevaluationofprograms• Investinrigorousresearch,includingcontrolledtrialstomeasurethe

impactofECDinterventions,aswellasimplementationresearchtoconfirmaccuracy .

• Buildcapacityofcommunityworkerscapacitytocollect,analyzeandusedatatoworkcross-sectorally .

• Testtheimpactofremoteinterventionsagainsttheimpactofinterventionsdeliveredin-person,allowingstakeholderstoassessthecost-benefittradeoffsofeachapproach .

• Sharecostandimpactdatainrealtime,toidentifybestpracticesandimproveoutcomes,withtheintentofstrengtheningplanning,policiesandservices .

SOURCE: J Wanless / International Rescue Committee


29

WhileCOVID-19hasgreatlydisruptedaccesstonurturingcareservicesinhumanitariansettings,remoteservicedeliveryoptionsprovideaviablealternative .Gindegi Gorondemonstratesthatablendednurturingcareinterventionofautomatedandlivecallsfromtrainedfacilitatorscanbeaneffectivemodalitytopromotenurturingcareinhumanitariansettings .ThepromisingresultsfromtheIRCpilotprojectsuggestthatscalingremotenurturingcareinitiativesisavaluableinvestmentinhumanitariansettings,particularlyincircumstanceswherethereislittlepossibilityforphysicalaccesstohighlyvulnerablepopulations .

Conclusion

Endnotes

1 Pia Britto et al., Nurturing Care: Science and Effective Interventions to Promote Early Childhood Development, The Lancet, 2017.

2 World Health Organization. “Nurturing care for early childhood development: Linking survive and thrive to transform health and human potential, https://bit.ly/3lnp5Th.

3 UNICEF Humanitarian Action Plan for 2020, https://bit.ly/35lpgJQ.

4 https://unesdoc.unesco.org/ark:/48223/pf0000266072

5 Seek Development, Moving Minds Alliance. Analysis of financing landscape for ECDiE. In press.

6 https://pubmed.ncbi.nlm.nih.gov/29791733/

7 UN Coordinated Appeal, https://bit.ly/3lmd15D.

8 UNHCR, Joint Government of Bangladesh - UNHCR Population Factsheet, October 3, 2020, https://bit.ly/32DMZTN.

9 UNHCR, Joint Government of Bangladesh - UNHCR Population Factsheet, October 31, 2020, https://bit.ly/32DMZTN.

10 UNHCR, Joint Government of Bangladesh - UNHCR Population Breakdown, October 31, 2020, https://bit.ly/2GXtDBx.

11 Hamadani, J. D., S. N. Huda, F. Khatun, and S. M. Grantham-McGregor. 2006. “Psychosocial Stimulation Improves the Development of Undernourished Children in Rural Bangladesh.” Journal of Nutrition 136: 2645–52

SOURCE: Iris Ebert / International Rescue Committee

International Rescue Committee Rescue.orgImplementing Evidence-Based Nurturing Care in Cox’s Bazar During COVID-1928

https://bit.ly/3lnp5Th

https://bit.ly/35lpgJQ

https://unesdoc.unesco.org/ark:/48223/pf0000266072

https://pubmed.ncbi.nlm.nih.gov/29791733/

https://bit.ly/3lmd15D

https://bit.ly/32DMZTN.

https://bit.ly/32DMZTN

https://bit.ly/2GXtDBx

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